OPERATIVE TREATMENT OF CHONDRAL DEFECTS IN THE HIP JOINT:
A SYSTEMATIC REVIEW
Mark A. Jordan, BS
University of Illinois – Rockford, IL
Geoffrey S. Van Thiel, MD/MBA
Rockford Orthopedic Associates – Rockford, IL
Rush University Medical Center – Chicago, IL
Shane J. Nho, MD
Rush University Medical Center – Chicago, IL
1 ABSTRACT
Young patients with cartilage defects in the hip present a complex problem for the
treating physician with limited treatment modalities available. Cartilage repair/replacement
techniques have shown promising results in other joints, however, the literature regarding the hip
joint is limited. The purpose of the current study is to conduct a systematic review of clinical
outcomes following various treatments for chondral lesions of the hip and define the techniques
for the treatment of these cartilage defects.
The full manuscripts of 15 studies were reviewed for this systematic review including
case studies, case series, and clinical studies. A variety of techniques have been reported for the
treatment of symptomatic chondral lesions in the hip. Microfracture, cartilage repair, autologous
chondrocyte implantation, mosaicplasty and osteochondral allografting have all been used in
very limited case series. Although good results have reported, most studies lack both a control
group and a large number of patients. However, the reported results in this paper do provide a
good foundation for treatments and stimulant for further study in an inherently difficult to treat
young patient population with articular cartilage defects in the hip.
2 INTRODUCTION
Cartilage damage in the hip presents a challenge to the surgeon due to its limited ability
for spontaneous regeneration,1 friability,2 and the difficult-to-replace properties of biological
hyaline cartilage.3 Outcome studies of procedures developed in the knee have been encouraging
and there has been a considerable amount of benchtop research into artificial cartilage
replacement, but to date, there is still no “perfect” solution to reproducibly replicate the loadbearing capacity and durability of native joint cartilage.3 While long-term outcome studies on
knee cartilage replacement and repair are becoming more prevalent in the literature, definitive
evidence-based treatment guidelines for chondral lesions of the hip have lagged behind.3-5
Causes of cartilage damage in the hip are numerous and include trauma,
femoroacetabular impingement (FAI), labral tears, osteonecrosis, osteochondritis dessicans,
degenerative joint disease, loose bodies, slipped capital femoral epiphysis, and hip dysplasia,
among others.6,7 Arthroplasty remains the gold standard treatment for diffuse osteoarthritis3 and
is considered a failure endpoint in most studies, but the current trend is to treat the underlying
morphological pathology in younger patients in an attempt to prevent progression to end-stage
disease. A major leap in both the diagnosis and treatment of intra-articular hip pathology
occurred with the advent of the “lateral approach to hip arthroscopy” in 1984, and the 2002
defining of femoroacetabular impingement syndrome highlighted that underlying morphological
conflicts are a major contributing factor to osteoarthritis in the hip.2 The implications in treating
these morphological conflicts, as well as the chondral lesions themselves, are profound. A recent
study, for instance, showed that 36% of Olympic or professional athletes undergoing hip
arthroscopy required decompression of a cam or pincer impingement.8 It has also been
demonstrated that labral tears can cause progression of osteoarthritis by increasing joint contact
stress by up to 92%,8 and that most cartilage injuries of the hip are associated with a torn
acetabular labrum.9
Advances in the understanding of femoroacetabular impingement syndrome are
progressing the understanding of cartilage damage in the hip. CAM lesions, in which the
anterior femoral head/neck junction has an abnormal protrusion causing impingement on the
anterior acetabulum, have been shown to cause chondral damage to the anterior acetabulum near
the rim in a fairly predictable and progressive manner.8 Pincer deformity, in which a retroverted
or deep acetabulum makes contact with a normal femoral neck, also has a recognized pattern of
chondral damage to the femur and a posterior-medial acetabular countercoup injury.6,8 As more
information has been gathered through arthroscopy on the patterns of chondral injury in these
hips, new classification systems have recently been published which an attempt to grade
acetabular chondral defects in a way which more accurately guides treatment.2,10 Konan et al10
tested the validity of a classification system based on the work of Ilizaliturri et al11 that divided
the acetabulum into 6 anatomical zones with vary degrees of cartilage injury and location in each
zone. They found good intra and inter observer reliability with this method.
In diagnosing chondral injuries of the hip, there is no specific physical examination
maneuver to assess for them.6 The typical presentation of intra-articular pathology is anterior
3 groin pain8, and accompanying lesions may present with more specific signs and symptoms.
Clicking or other mechanical symptoms are common in a labral tear,6 while the impingement
test, in which the hip is flexed, internally rotated, and adducted, nearly always elicits pain in
femoroacetabular impingement.8 In imaging the patient with hip pain, radiographs are the most
useful initial tool and can reveal most bony pathology.6 While MRI is useful for looking at soft
tissue and can provide information regarding the status of the cartilage,6 MRI arthrogram is a
more useful modality for identifying these lesions. However, it has been shown to accurately
diagnose only 76% of acetabular labral tears and 62.7% of articular cartilage lesions when
compared with arthroscopy.12 Diagnostic joint injection with lidocaine during MRI arthrogram
can help further delineate whether the pain originates intra-articularly.2 Variations such as
delayed gadolinium-enhanced MRI have the potential to accurately diagnose focal chondral
defects in a non-invasive manner,3,7 but the gold standard is still direct visualization by
arthroscopy.
Importantly, Suzuki et al13 showed that cartilage lesions will often not improve after
correction of the underlying pathologic mechanism. The authors completed second look
arthroscopy after pelvic osteotomies and found no improvement in the majority of cases with
regard to articular cartilage lesions present at the time of the index operation. Thus, numerous
joint-preserving treatments exist for chondral and osteochondral lesions of the hip, mirroring the
treatment options in the knee. These include debridement,8,14,15 microfracture,6-8,15-19 autologous
chondrocyte transplantation,14,20 osteochondral autograft transplantation (OATS) and
mosaicplasty,4,17,21,22 osteochondral allograft transplantation,5,23 partial resurfacing prostheses,24
and recently, suturing techniques7 as well as fixation with a fibrin adhesive for delamination
lesions.25,26 Indications vary between the procedures. Microfracture, for instance, requires intact
subchondral bone on which a stable marrow clot can form, and is most commonly used in fullthickness lesions6-8. Osteochondral autografts and allografts, on the other hand, have been used
for defects which involve a combination of both cartilage and subchondral bone
destruction.4,5,17,23 While hip arthroplasty offers both good pain relief and function, younger
patients face the likely prospect of revision in the future and thus our review is limited to nonarthroplasty techniques.5
There are a multitude of treatment options available for chondral defects in the hip,
however, a surgeon who encounters such a lesion is left with little guidance on the best manner
in which to proceed. No recent systematic reviews currently exist in the literature to provide the
surgeon with evidence-based recommendations on treating these cartilage defects. Additionally,
due to the young nature of the field, many innovative techniques have made their way into the
literature in the past few years.
The object of this study was to conduct a (1) systematic review of clinical outcomes
following various treatments for chondral lesions of the hip; (2) define the techniques for the
treatment of cartilage defects in the hip that have been published; (3) to provide treatment
recommendations based on the best currently available evidence; (4) to highlight new and
4 innovative techniques in recent case studies and to (5) highlight gaps in the literature which
require further research.
METHODS
Literature Search
We searched Pubmed (1948 to March Week 1 2012) using the following key words: (hip
OR acetabulum OR femoral) AND (cartilage OR osteochondral OR articular). Search terms
were broad as to encompass all possibilities for applicable studies. All review articles were then
manually cross-referenced to make certain no relevant studies were missed.
Inclusion criteria were (1) studies that reported on clinical outcomes or techniques following
non-arthroplasty treatment for the spectrum of chondral lesions of the hip including focal and
diffuse articular disease on the femur and/or acetabulum. We excluded review articles.
Data Abstraction
The data from each study that met the inclusion criteria was abstracted by one reviewer
(MJ) and verified by another (GV). Study data which was determined to be of interest a priori
included the type of treatment, year of publication, study period, type of clinical study,
inclusion/exclusion criteria, number of patients enrolled, number of patients available for followup, age, minimum follow-up, length of follow-up, gender, concomitant procedures, classification
of pre-operative arthritis, post-operative rehabilitation, and statistical analysis used. Preoperative
and postoperative data of interest was patient satisfaction, clinical outcome scores, and the
amount of people that ultimately failed treatment (requiring resurfacing or arthroplasty) was also
recorded.
RESULTS
We obtained 2794 articles from Pubmed. Of these articles, we screened the articles by
article title relevance and were left with 25 studies. These articles were then further screened to
remove review papers. The full manuscripts of 15 studies were reviewed for this systematic
review including case studies, case series, and clinical studies. Due to the low number of
reported cases, the majority of studies were case reports or small case series. Thus, pooling of
data was impossible and a discussion of the relevant studies was completed. The data is
summarized in tables 1 and 2.
OPERATIVE PROCEDURES
Autologous Chondrocyte Implantation (ACI)
ACI has been used extensively in the knee with good literature support. The technique
includes the harvest of chondrocytes with growth and expansion at an off-site facility. These
cells are then re-implanted into the affected area. There are only limited reports of the use of
ACI in the hip. This process is most likely complicated by the difficulty with harvest in the hip
or the need to complete a surgical procedure on an unaffected joint (knee). Regardless, Akimau
et al20 was the first to describe the use of autologous chondrocyte implantation (ACI) in the hip.
They reported a case in a 31-year-old male with osteonecrosis of the femoral head following
open reduction internal fixation for a traumatic fracture dislocation. Initial Harris Hip Score
(HHS) before ACI was 52 and the patient required a crutch. Femoral head defects were filled in
5 with a greater trochanter bone graft, and chondrocytes were obtained from the femoral trochlea
and transplanted under a collagen patch after culture expansion. Sixteen-months post-ACI, HHS
was 76, and there was no use of any walking aids, ROM was markedly improved, and the patient
was able to run on the spot as well as walk more than a mile. A second look biopsy
demonstrated 2 mm thick cartilage, predominantly fibrocartilage. CT was performed at 18
months post-ACI, and demonstrated retention of joint space despite cystic sclerotic changes of
the previous osteonecrosis.
These limited results have been supported in a larger study by Fontana et al14 with a
retrospective comparative level III study between ACI and simple debridement. Inclusion
criteria included Tonnis grade 2 arthritic changes on radiograph with grade 3 hips excluded.
There were a total of 15 patients in the ACI group and 15 patients in the debridement group, all
having 3rd or 4th degree (Outerbridge classification) chondral lesions of 2 cm2 or more. ACI was
performed first by doing an arthroscopic evaluation, debridement and cartilage biopsy from the
pulvinar. These cells were then cultured and re-implanted at a second stage arthroscopy using a
three-dimensional polymer scaffold. Mean age in the ACI and debridement groups was 40.7 and
42.3, respectively. Mean defect size was 2.6 cm2 in both groups. Follow-up period was 73.8
months in the ACI group and 74.3 months in the debridement group. Pre-operative Harris Hip
Score (HS) was 48.3 for the ACI group and 46 for the debridement group (not statistically
significant). At last clinical evaluation (approximately 5 years), HS was 87.6 in the ACI group
and 56.3 in the debridement group. This difference was statistically significant (p < .001). No
post-operative radiographs, MRI, or arthroscopy was done, so it could not be verified whether
viable cartilage truly formed. The authors suggest that arthroscopic debridement has limited
utility in treating chondral lesions of the hip, especially in lesions > 3 cm2 due to the fact that
these patients had the worst outcomes.
Microfracture
Microfracture has been a widely accepted technique for the treatment of cartilage lesions
in the knee. However, due to both technical difficulty and the relatively new expansion of hip
arthroscopy, microfracture has only experienced limited exploration in the hip. Byrd et al27 was
one of the first to describe microfracture in the hip. In 220 arthroscopic cases he noted that 9
patients had an “inverted” labrum as a potential cause of secondary osteoarthritis. Of these 9
patients, all had grade IV changes on their acetabulum and 3 of them received microfracture for
an isolated defect. At final 2 year follow-up, the 3 patients with microfracture were the only
patients that returned to an active lifestyle.
Haviv et al15 subsequently completed a large comparative study with 166 patients that had
grade 1 to 3 chondral damage and underwent hip arthroscopy with a femoral osteochondroplasty.
Additionally, 29 of 135 patients with grade 2 and 3 lesions were treated with microfracture.
Mean follow-up was 22-months. Interestingly, the 29 patients treated by microfracture had a
significantly higher NAHS than those with grade 2 and 3 lesions treated by debridement (post-op
90.2 vs. 80.2, pre-op 70.0 vs. 67.6). However, to be a candidate for microfracture, the lesion had
to be < 300 mm2, but mean lesion size was not provided for the debridement group. Without this
6 information there is the potential for bias based on the defect size. In another interesting study,
Philippon et al18 followed 9 patients undergoing revision arthroscopy for a variety of conditions
after having microfracture of a full-thickness acetabular defect done at the primary arthroscopy.
Average chondral lesion size at primary arthroscopy was 163 mm2, all lesions were located in the
superior acetabulum. Mean time from index arthroscopy to revision procedure was 20 months.
Mean percent fill of the defects was 91%. One patient had diffuse osteoarthritis at primary
arthroscopy but wished to proceed with microfracture to finish out his baseball season, and his
percent fill at 10 months was 25% with grade 4 repair tissue (full-thickness cartilage loss). Eight
out of nine patients had 95% to 100% fill of the defect, with grade 1 or 2 repair tissue (normal
cartilage or mild fibrillation/discolored/softer-than-normal cartilage, respectively).
However, Horisberger et al16 has shown less than ideal results with microfracture. In this
retrospective study, 20 patients with an average age of 47 years were identified that underwent
hip arthroscopy with Outerbridge grade II or higher lesions. The mean follow-up was 3 years.
Fourteen patients had grade IV lesions in the impingement zone, six patients had grade III
lesions and three patients had grade IV changes on the femoral head. Ten patients went on to
require total hip arthroplasty. Fifty percent of the microfracture patients required THA and 2 of
the 3 patients with grade IV femoral head changes required THA. The authors concluded that
patients with Tonnis grade III osteoarthritis should not undergo hip arthroscopy and if grade IV
femoral changes are found in addition to the acetabular arthritis, total hip arthroplasty will most
likely be required. Overall, microfracture has shown some guarded promise from both a clinical
and biologic standpoint. However, the available literature does not control for external variables
and, further well controlled studies are necessary before any definitive conclusions can be drawn.
Synthetic Treatment
There has been one clinical report from Field et al28 describing the use of an
osteochondral synthetic plug for the treatment of acetabular cystic cartilage lesions in four
patients. All four patients underwent hip arthroscopy followed by the antegrade insertion of a
plug through the ilium until the surface of the plug was flush with the articular surface. At 10
month follow-up, patients reported increased function with an improvement in the non-arthritic
hip score from 54 to 84. One patient continued to have moderate pain and a second look
arthroscopy with debridement and biopsy showed bone formation of the plug. CT and MRI at 6
months showed incorporation and continued healing of the plug. The authors concluded that this
was a viable treatment for cavitary lesions in the acetabulum. Perhaps, the most interesting
aspect of this article was the use of an antegrade technique to place the graft flush with the
acetabular articular surface. This technique could theoretically be used with a multitude of other
grafts.
Mosaicplasty
Mosaicplasty involves the use of multiple small autograft plugs to replace an articular
defect. This technique was first described in the knee, but has been modified for use in the hip.
Multiple authors have detailed the technique with a variety of modifications for the origin of the
7 osteochondral graft. Some have described a harvest site from the knee is a separate procedure,
whereas others have utilized the inferolateral femoral head of the affected hip (Figure 1).
Girard et al4 completed a prospective study evaluating the results of mosaicplasty to the
femoral head utilizing a surgical dislocation of the hip in 10 patients. Etiology of the lesions
included Legg-Calve-Perthes disease, spondylo-epiphyseal dysplasia, and epiphyseal dysplasia.
Exclusion criteria included age above 25 years, osteonecrosis, or acetabular chondropathy.
Mean patient age was 18 years. Mean femoral head lesion size was 4.8 cm2. Plugs were
obtained from the most inferior non-weight-bearing portion the femoral head, and cancellous
bone was packed in between the plugs at the recipient site. Mean follow-up was 29.2 months.
Mean pre-op Postel Merle d’Aubigne score was 10.5 and at last follow-up was 15.5. Mean HHS
increased from 52.8 to 79.5. There was one sciatic nerve palsy that improved spontaneously
after 3 months, and no hip arthroplasty was required at final follow-up. CT arthrogram at 6
months revealed excellent autograft incorporation with intact cartilage for all 10 plugs.
Hart el al21 has also reported a case of mosaicplasty for an osteochondral defect in the
femoral head. The defect arose in a 28-year-old patient due to migration of a resorbable screw
into the hip joint that was used for open reduction internal fixation of an acetabular fragment
following a posterior hip dislocation. A round defect (14 mm diameter, 16 mm depth) was
identified on the posterior non-weightbearing portion of the femoral head. A mosaicplasty with
an open approach was undertaken using four cylindrical osteochondral grafts from the lateral
femoral condyle. HHS before the revision procedure was 69, 6 months post-operatively the
score was 100 with full range of motion and absence of hip pain.
In another small case series, Nam et al17 reported two cases of mosaicplasty for correction
of osteochondral injuries to the femoral head sustained after traumatic posterior hip dislocation.
In one case, an osteochondral fracture was stabilized with bioabsorbable pins, but there was a
full-thickness cartilage defect in the anterior-superior weight-bearing zone of the femoral head.
Three osteochondral plugs were transferred from the lateral knee to treat this lesion (Figure 2). In
the other case, a femoral head fracture was stabilized with screws and an osteochondral plug was
obtained from the most inferior non-weight-bearing portion of the femoral head and transferred
to the full-thickness chondral lesion at the fracture apex. MRI showed incorporation of both
grafts and the patients returned to their baseline activity level. However, it should be noted that
these patients did not have symptoms prior to their injury and procedure.
Lastly, Sotereanos et al22 published a case of a 32 year old male with bilateral
osteonecrosis of the femoral head. He underwent free fibular grafts to both femoral heads, but
continued to have significant pain and was scheduled for a total hip arthroplasty. At the time of
the arthroplasty his articular cartilage was found to be intact except for one discreet area of
softening. A mosaicplasty with grafts from the inferolateral head was done instead of the
arthroplasty. At 66 month follow up his pain score has decreased from a preoperative 90 to 9.
The case reports of mosaicplasty have been positive, but it should be noted that half of these
patients did not have problems before an injury and mosaicplasty was done in anticipation of
8 future issues. Regardless, mosaicplasty clearly represents a technique that can be completed
with local osteochondral plugs and provides a useful tool for the treating surgeon.
Osteochondral Allograft Transplantation
Mosaicplasty has been shown to be a useful technique, but there can be donor site
morbidity and the knee experience has also shown that there is a limit to the size of the treatable
defect. Allograft transplantation has also been shown to be a successful technique for the
treatment of cartilage defects. Meyers et al5 was one of the first to describe the use of
osteochondral allografts in the hip. They treated 21 patients with AVN of the femoral head with
a femoral head osteochondral allograft of varying sizes. Failure was defined as moderate to
severe pain or collapse of the allograft. The authors found that 50% of the steroid induced
osteonecrosis patients experienced a failure, whereas the success rate in non-steroid induced
osteonecrosis was 80%. They concluded that this is a viable treatment option for the young
patient with non-steroid induced osteonecrosis of the femoral head.
Krych et al23 has also described the results in 2 patients of an osteochondral allograft for
the treatment of large cartilage defects with associated bone loss. One case involved a 24-yearold female with previous failure of a femoral neck osteoplasty with a periacetabular cyst (18 mm
x 18 mm) in the superior dome. The other case was a 32-year-old male that was treated with
bone cement for fibrous dysplasia of the acetabulum with pain and protruding cement. Both
patients underwent an open surgical approach and osteochondral grafting of the defect from
either an allograft acetabulum or medial tibial plateau. In the first case, MRI at 12 months
demonstrated incorporation of the allograft with joint congruity. Harris Hip Score (HHS) was 75
pre-operatively and 97 at 2 year follow-up. In the second case, preoperative and postoperative
HHS at 3 year follow-up were 79 and 100, respectively, and MRI at 18 months demonstrated
incorporation of the allograft. The authors felt that the medial tibial plateau had better cartilage
and congruency in the treatment of an acetabular defect.
These two studies have reported very good results and provide a good foundation for
future study. However, the indications will need to be continually refined in order to determine
the specific etiologies of hip pathology that respond well to allograft transplantation. It should
also be noted that this technique does require and open surgical dislocation of the hip with its
associated risks and limitations.
Articular Cartilage Repair
Many of the above mentioned procedures require a large open approach and are not
techniques that can be utilized with hip arthroscopy. Thus, Sekiya et al19 described a case of a
17-year-old male high school wrestler with bilateral CAM lesions as well as a 1 cm delaminated
unstable cartilage flap in the anterior-superior acetabulum. The authors arthroscopically
performed a microfracture underneath the flap of anterior superior acetabular cartilage and, due
to flap instability, completed a suture repair of the cartilage with an absorbable polydiaxanone
monofilament. This suture was chosen since it absorbs at 6 weeks, before full weight bearing,
and may prevent abrasion of the femoral head. At 2 year follow-up the patient reported 95% of
normal function for both hips. Modified Harris Hip Score (MHSS) was 96 at last follow-up, Hip
9 Outcome Score Activities of Daily Living subscale was 93, and Hip Outcome Score Sports
subscale was 81. This case presents direct cartilage repair as a possible technique to treat large
delaminated full-thickness acetabular cartilage repairs and potentially prevent progression.
A larger study using a slightly different technique was completed by Tzaveas et al26.
This prospective study of 19 patients analyzed the efficacy of using fibrin adhesive for
arthroscopic repair of chondral delamination lesions with intact gross cartilage structure.
Concurrent pathology was present including 15 labral tears and 18 CAM impingements that were
treated simultaneously. The correction of the debrided cartilage involved creating an incision at
the periphery of the acetabular labrum and passing an awl underneath to microfracture the
subchondral bone. The pocket was then filled with fibrin glue, and the cartilage was pressed
down until the adhesive had set (< 2 minutes). Five patients underwent revision arthroscopy for
various reasons at a later date, and the chondral repair appeared intact in all 5 cases. Mean
MMHS was 53.3 pre-op and 80.3 at 1 year. Mean pain score pre-op was 15.7 and 28.9 at 1 year.
The authors discuss that fibrin seems to have good results in short-term follow-up, and longer
follow-up studies will be needed.
DISCUSSION
The gold standard for treatment of cartilage defects in the hip continues to be hip
arthroplasty. However, there are significant risks and limitations associated with arthroplasty in
the young patient. Thus, a variety of techniques have been reported for the treatment of these
symptomatic chondral lesions. Microfracture, cartilage repair, autologous chondrocyte
implantation, mosaicplasty and osteochondral allografting have all been used in very limited case
series. Although good results have reported, most studies lack both a control group and a large
number of patients. In order to build on the current reports and recommendations, further study
is required. Nonetheless, the reported results in this paper do provide a good foundation for
treatments that can provide relief and potentially delay arthroplasty in its associated morbidities
in an inherently difficult young patient population.
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Van Stralen RA, Haverkamp D, Van Bergen CJ, Eijer H. Partial resurfacing with varus osteotomy for an osteochondral defect of the femoral head. Hip Int. Jan-­‐Mar 2009;19(1):67-­‐70. 12 25. 26. 27. 28. 29. 30. ŸŸStafford GH, Bunn JR, Villar RN. Arthroscopic repair of delaminated acetabular articular cartilage using fibrin adhesive. Results at one to three years. Hip Int. Nov-­‐
Dec 2011;21(6):744-­‐750. ŸŸ The authors report the results in 43 patients of a microfracture technique with
cartilage repair using fibrin glue. This is the largest study that evaluates repair of the
delaminated cartilage in the anterosuperior dome. The mid-term results are very
encourage for this technique.
Tzaveas AP, Villar RN. Arthroscopic repair of acetabular chondral delamination with fibrin adhesive. Hip Int. Jan-­‐Mar 2010;20(1):115-­‐119. Byrd JW, Jones KS. Osteoarthritis caused by an inverted acetabular labrum: radiographic diagnosis and arthroscopic treatment. Arthroscopy. Sep 2002;18(7):741-­‐747. ŸField RE, Rajakulendran K, Strambi F. Arthroscopic grafting of chondral defects and subchondral cysts of the acetabulum. Hip Int. Jul-­‐Aug 2011;21(4):479-­‐486. Ÿ This study reports the results in 4 patients of a synthetic plug to treat acetabular cystic
defects. However, the interesting aspect of this report is the approach used to reach the
acetabulum. The authors used an antegrade access channel through the ilium. They were
able to place the graft flush with the acetabular cartilage.
Rittmeister M, Hochmuth K, Kriener S, Richolt J. [Five-­‐year results following autogenous osteochondral transplantation to the femoral head]. Orthopade. Apr 2005;34(4):320, 322-­‐326. Anderson LA, Crofoot CD, Erickson J, Morton DA, Peters CL. Acetabular osteochondroplasty and simultaneous reorientation: background and validation of concept. Orthopedics. May 2010;33(5). 13 FIGURES
Figure 1 – Mosaicplasty – autograft taken from the affected femoral head29.
Figure 2 – Mosaicplasty – autograft plugs taken from the knee and placed in the femoral
head17.
14 15 1 2 3 TABLES
Table 1- Table 1: Patient demographics. CPM = continuous passive motion, ACT = autologous chondrocyte transplanation
Author
Age
[years (range)]
Number of Concomitant Open vs.
patients and Procedures[% Arthroscopic
gender
of patients]
[n(%male)]
Post-op Rehab
Microfracture
Horisberger16
47.3 (22-65)
20 (80%)
100%
Arthroscopic
Partial weight bearing at 4-6 weeks, low impact
sports after 6 weeks, high impact sports after 3
months
*non-microfracture patients had full weight
bearing as tolerated post-operatively
Phillipon18
37.2 (21-47)
9 (55.6%)
Yes, but %
not specified
Arthroscopic
Toe-touch weight bearing until 8 weeks with
concurrent CPM, return to sport at 4-6 months
Microfracture vs. debridement/radiofrequency ablation
Haviv15
37 (14-78)
166 (79.5%) 100%
Arthroscopic
Weight bearing as tolerated from day 1, jogging
allowed at 4-6 weeks
Mosaicplasty /OATS
Girard4
18 (15-21)
10 (70%)
Open
Hart21
28
1 (male)
Yes, but %
not specified
0%
Nam17
18 (15 and 21)
2 (50%)
100%
Open
Rittmeister29
Sotereanos22
n/a
36
5 (n/a)
1 (male)
n/a
0%
Open
Open
CPM for 1 week, non-weight bearing for 6 weeks,
then full weight bearing as tolerated
CPM early, partial weight bearing at 6 weeks, full
weight bearing at 10 months
Non-weight bearing for 6 weeks, increased as
tolerated thereafter
n/a
Toe-touch weight bearing at 8 weeks, then full
weight bearing as tolerated
100%
Open
Osteochondral allograft transplantion
Krych23
28 (24 and 32)
2 (50%)
Open
8 weeks of CPM with protected weight bearing,
high impact activity at 6 months
Akimau20
4 5 6 7 31
1 (male)
Open
CPM for 48 hours, partial weight bearing for 8
weeks
Autologous chondrocyte transplantation vs. debridement
Fontana14
41.5 (20-53)
30 (40%)
0%
Arthroscopic
Partial weight bearing at 2 weeks in debridement
group and at 4 weeks in the ACT group. Passive
and active physiotherarpy for the first 4 weeks.
Fibrin adhesive
Tzaveas26
36 (18-57)
19 (73.7%)
100%
Arthroscopic
Toe-touch wt bearing for 4 weeks, high impact
exercise allowed at 3 months
Synthetic osteochondral plugs
Field28
48.5 (31.6-63.3)
4 (25%)
75%
Open
50% weight bearing for 6 weeks, full weight
bearing by 8 weeks
Absorbable sutures combined with microfracture
Sekiya19
17
1 (male)
100%
Arthroscopic
30% weight bearing for 6 weeks, full weight
bearing at 8 weeks, and progression of resistive
weight-bearing exercises thereafter
Acetabular rim resection
Anderson30
19.8 (15-29)
100%
Arthroscopic with
pelvic tunnel
No comment other than ambulating with
crutches at 6 weeks
Open
n/a
4 (75%)
0%
Partial resurfacing prosthesis with high varus osteotomy
Van Stralen24
16
1 (male)
100%
Table 2 - Table 1: Outcomes following various treatment modalities for cartilage lesions. PMdAS = Postel Merle d’Aubigne score, HHS = Harris Hip
Score, MHHS = Modified Harris Hip Score, NAHS = Non-Arthritic Hip Score, ROM = range of motion, THA = total hip arthroplasty.
Author
# of
patients
Duration of follow- Outcomes
up [months (range)] Measure(s)
Pre-op Value [mean
(range)]
* = 95% CI
Post-op Value [mean
(range)]
Resurfacing/
Arthroplasty
[n(%)]
* = 95% CI
Microfracture
Horisberge 20
r16
Phillipon18 9
3.0 (1.5-4.1)
NAHS
47.15 (23.75 – 66.25)
78.3 (63.75 – 95.0)
10 (50%)
20 (9-36)
% fill of defect
n/a
91%
2 (22.2%)
MHHS (all groups): 70.8
MHHS (all groups): 86.1
2 (1.2%)
Microfracture vs. debridement/radiofrequency ablation
22 (n/a)
Haviv15
166 (19 in
MHHS and
17 microfx
subgroup)
Mosaicplasty /OATS
Girard4
10
Hart21
Nam17
1
2
29.2 (20-39)
6
Case 1: 12
Case 2: 60
Rittmeister 5
57 (n/a)
Sotereanos
66
29
22
1
Osteochondral allograft transplantion
Krych23
2
Case 1: 24
Case 2: 36
5
n/a (9 – 63)
Meyers
21
NAHS
NAHS (all groups): 69.8
(79.7 – 92.5)*
NAHS (all groups): 84.8 (79.2
– 90.4)*
NAHS improvement
(microfracture vs.
debridement): 20.2 vs. 12.6
(significant)
HHS and Postel
Merle d’Aubigne
score
HHS
Pain and
mechanics
HHS: 52.8 (35-74) PMdAS: 10.5 (8-13) HHS: 79.5 (65 – 93)
PMdAS: 15.5 (12-17)
0
69
Case 1: femoral head
osteochondral fracture
with full-thickness
cartilage loss
Case 2: same
100
Case 1: ambulating without
pain at 12 weeks, no pain at
last follow-up
Case 2: ambulating without
pain or assistance at 12 wks,
at last follow-up no pain or
difficulties
0
0
Progression to
THA
HHS and Pain
n/a
n/a
4 (80%)
HHS: 45 (retrospective)
Pain: 90/100
HHS: 100
Pain: 0/100 (at 17 months)
0
Case 1: 79
Case 2: 100
38% failure
0
52
76
0
ACT HHS: 48.3 (45.4 –
51.2)*
Debridement HHS: 46.4
(43.5 – 49.3)*
ACT HHS (5 year): 87.7
(84.5-90.3)*
Debridement HHS (5 year):
56.3 (53.4 – 59.1)*
n/a
HHS
Case 1: 75
Case 2: 97
Failure rate (failure n/a
= mod/severe
pain or THA)
Autologous chondrocyte implantation
Akimau20
1
18
HHS
Autologous chondrocyte transplantation vs. debridement
Fontana14 30 (15 in
ACT:
HHS and Pain
each
73.8 (72-76)
Score
subgroup)
Debridement:
(0 = max pain,
74.3 (72-76)
44 = no pain)
18 5 (23%)
Fibrin adhesive
Tzaveas26
19
12
Synthetic osteochondral plugs
Field28
4
10 (8-11)
ACT Pain: 20 (18.7 –
21.38)*
Debridement Pain: 20
(18.9 – 21.1)*
ACT Pain: 40 (38.6 – 41.4)*
Debridement Pain: 35 (33.2 –
36.8)*
MHHS (x 1.1) à
Pain Score à
Function Score
à
53.3
15.7
37.2
80.3
28.9
44.1
1 (5.3%)
NAHS (only
obtained in 3 out
of 4 patients)
53.8 (43.8 – 70.0)
84.6 (range, 78.8 – 87.5)
- obtained at 6 months
0
Pain and decreased ROM
MHHS: 97
Pain-free 90% of time, 2/10
at worst
0
67.5 (58-74), obtained
retrospectively
98 (95-100)
0
Flexion/extension: 110-01⁰
Abduction/adduction: 400-15⁰
External/internal rotation:
25-0-0⁰
Significant pain
Flexion/extension: 110-0-50⁰
Abduction/Adduction: 35-020⁰
Extension/internal rotation:
60-0-20⁰
Pain free
0
Absorbable sutures combined with microfracture
Sekiya19
1
27
MHHS (post-op)
Pain
Acetabular rim resection
Anderson3 4
0
38 (34-42)
HHS
Partial resurfacing prosthesis with high varus osteotomy
Van
1
24
ROM and Pain
24
Stralen
8 9 19